Case Report of Pneumonia

Introduction

This case report presents a clinical overview of a man suffering of pneumonia, made
by a medical examiner.
Name of the patient: Robert Forester
Gender: Male
D.O.B: 19 February 1962
Age: 54
Suffering of: pneumonia
Hospitalization: transplantation ICU
Background information
We report about our 54 years old patient admitted to the hospital
complaining of respiratory insufficiency, sever caught and fever for the past four
days, most likely due to a case of pneumonia.
Problems and Solutions
He presented at the ER with a harsh, productive cought for the past four day
prior being seen by a physician. He also developed a fever, shaking and malaise
along with the cought. One day ago he developed pain in his right chest that
intensifies with inspiration.
Medical Hystory
The patient medical history is notable for a orthotopic heart transplantation due to a
dilatative cardiomyopathy in 2006. He successfully recovered from the
transplantation and ten years later he presented at the ER with respiratory
insufficiency.
Family history
The patients mother also suffered of a cardiomyopathy approximately at the same
age as the patient, and the father was diagnosed with pulmonary cancer most likely
due to the smoking and alcoholic history.

Social and personal history

He smokes one pack of cigarettes per day, and drinks almost a bottle of wine in
maximum two days. He says he doesnt use hard drugs, like cocaine or IV drugs like
heroin but he admitted the use of marijuana at least once a month.
Physical examination
He presents fever of 38,7 celsius grades, pulse of 152/90, regular heart beat, and a
respiratory rate of 24/minute. Examination of the neck reveals a large, hard lymph
node in the right supraclavicular fossa. Both lungs are resonant by percussion with
two exceptions: the right mid-anterior and left mid-lateral lung fields. Ascultation
reveals bilateral diminished vesicular breath sounds.
Investigations
An x-ray of the lungs PA (postero-anterior view) and lateral reveals an acute
pneumonia in the right middle lobe and left mid-latteral lobe of the lungs.
Examination of the sputum: Sputum is thick and yellow with streaks of blood and
demonstrates the presence of atypical cells. A microbiological examination of the
sputum and also a blood test to find out if there are changes in the number of blood
cells.
Diagnosis
The pacient is suffering of pneumonia, caused by a Staphylococcus aureus bacteria.
The diagnosis is confirmed by the x-ray who demonstrates the infiltrated lungs and
by the percussion resonance exceptions. The diagnosis is confirmed also by the
microbiological results who shows the Staphylococcus aures infection wich most
likely caused the fever wich is a sign of bacterial infection. The blood test reveald a
WBC count of 17,000/mm3, neutrophilis 70%, bands 15% and lymphocytes 15%,
wich are all a sing of bacterial infection.
Recomandation
Treatment: the patient should be treated with antibiotics like IV cephalosporins and
also given IV fluids.
Concerns: the patient should be regularly examined for signs of bacterial infection
or pneumonia clinical signs.
Expectations: the symptoms should settle down and the patient will be discharged.
He will be readmitted in a few weeks, after the signs of infection disappear, for a xray who will confirm that the treatment was helpful.

Thank You!
Mihai Cobzaru, MG II, grupa V, subgrupa IX